Acute Contaminant Breakthrough in Double-Pass Reverse Osmosis Water for Online Hemodiafiltration: A Monitoring Blind Spot, “The Samovar Makers’ Phenomenon”

1. Association for the Advancement of Medical Instrumentation. Water Quality for Hemodialysis and Related Therapies. ISO 13959:2020.

2. Ward RA. Environmental contaminants in hemodialysis: the subtle trap of sub-threshold bioaccumulation. J Nephrol. 2019;32(4):511-9.

3. D'Haese PC, De Broe ME. Trace elements and heavy metal toxicities in end-stage renal disease patients. Kidney Int. 2021;99(3):562-75.

4. Flendrig JA, et al. Hard-water syndrome: severe calcium and magnesium toxicity during hemodialysis. Lancet. 1976;308(7981):350-3.

5. Saha JC, et al. A review of arsenic toxicity: gastrointestinal pathology and systemicmanifestations. Clin Toxicol. 1999;37(3):325-47.

6. Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003;79(933):391-6.

7. Argiles A, et al. Sodium kinetics and blood pressure fluctuations during modern high-flux hemodialysis. Nephrol Dial Transplant. 2015;30(7):1214-22.

8. Brunet P, et al. Nitric oxide precursors and intradialytic hypotension: the role of dialysate nitrate contamination. Hemodial Int. 2001;5(2):89-94.

9. Alfrey AC, et al. Dialysis encephalopathy syndrome: possible aluminum and trace metal etiology. N Engl J Med. 1976;294(4):184-8.

10. Goyer RA. Lead toxicity: from heme inhibition to peripheral neuropathy. Environ Health Perspect. 1993;100:177-87.

11. Indika SR, et al. Dialysate-induced methemoglobinemia and refractory anemia from agricultural nitrate runoff. Am J Kidney Dis. 2022;79(5):702-9.

12. Wright RO, et al. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med. 1999;34(5):646-56.

13. Tielemans C, et al. Refractory anemia in hemodialysis patients: link to trace element contamination and sub-clinical hemolysis. Nephron Clin Pract. 2014;126(3):115-23.